Purpose: To explore the impact of a context-adapted decision aid and an online training about shared decision-making (SDM) about goals of care on the level of involvement of elderly patients by intensivists in SDM about goals of care and quality of goals of care discussions (GCD) in an intensive care unit. Methods: This was a three-phase before-after mixed-methods implementation study conducted in an ICU in Lévis, Quebec, Canada. We followed the StaRI and COREQ reporting guidelines. We recruited patients aged ≥ 65 and their attending intensivists. We video-recorded GCD in three phases: Phase I: GCD without a decision aid; Phase II: GCD with a decision aid about goals of care but no online training; and Phase III: GCD with both a decision aid about goals of care following online training about SDM. All GCD recordings were transcribed verbatim. We measured the level of patient engagement by intensivists in SDM about goals of care through the OPTION scale and evaluated GCD quality using the Audit of Communication, Care Planning, and Documentation (ACCEPT) indicators. A qualitative thematic analysis of the encounters transcriptions was also performed. Results: Out of 359 eligible patients, the study included 21 patients (71% males; median age, 77 years; 57% without high school diploma) and 5 intensivists (80% male; median age, 35). Despite completing online training, the decision aid was never used in recorded encounters. We did not perform any tests of statistical significance to compare results in each study phase because of small sample sizes over each phase. OPTION and ACCEPT scores were low in each phase, but physicians did engage in GCD. We found that 76% of the goals of care recorded in medical records after the discussion were consistent with preferences expressed by patients during recorded observations. Several patients expressed confusion about GCD. Barriers identified by intensivists leading GCD include physician attitudes, challenges to performing GCD along with the demands of the intensive care unit, misunderstandings, and lack of training. Facilitators include a patient-centered approach, a clear decision aid, and positive patient attitudes. In future work, an environment that supports physicians in performing GCD, promotes earlier and higher quality patient GCD before admission to the intensive care unit, and encourages meaningful SDM in critical care must be assessed as pathways to successful intensive care unit GCD. Conclusion: A context-adapted decision aid about goals of care was created in addition to a complementary online training module. The online training was completed by all participating physicians but no increased involvement of patients in SDM during intensive care unit GCD was observed, and use of the decision aid was also not observed. We found several communication barriers that will need to be explored to improve intensive care unit GCD.

The authors have declared no competing interest.

NCT04034979

https://www.researchprotocols.org/2016/1/e24/authors

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191844

PA (the principal investigator) received salary awards from the CIHR as an Embedded Clinician Researcher (#201603) and the FRQS as a Clinical Scholar (#283211). The project was funded by the Canadian Frailty Network (CAT 2015-35). The funding agreement ensures the authors' independence in designing the study, writing, and publishing this article. The information provided or views expressed in this article are the responsibility of the authors alone.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The project was approved by the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) Research Ethics Board (Certificate #2017-001). A member of the research team obtained written consent to participate from each patient. Family members wishing to participate also completed a consent form. Patients, family members, and physicians were made aware that it would not be possible to identify individual participants in the published results.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

All anonymized data produced in the present study are available upon reasonable request to the authors.